Cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder

Discusses the cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder (OCD). Over the past 15 years, cognitive-behavioral psychotherapy has emerged as the psychosocial treatment of choice for OCD across lifespan. Unlike other psychotherapies that have been applied usually unsuccessfully to OCD, cognitive-behavioral treatment (CBT) presents a logically consistent and compelling relationship between the disorder, the treatment, and the specified outcome. Nevertheless, despite a consensus that CBT is usually helpful, clinicians routinely complain that patients will not comply with behavioral treatments and parents routinely complain that clinicians are poorly trained in CBT, with the result that many if not most children and adolescents are denied access to effective psychosocial treatment. This unfortunate situation may be avoidable, given an increased understanding regarding the implementation of CBT in children and adolescents with OCD. To this end, we review the principles and the practical aspects of the cognitive-behavioral treatment of OCD in youth, move on to discuss empirical studies supporting the use of CBT in the pediatric age group, and conclude by discussing directions for future research.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Comorbidity of Pediatric Obsessive–Compulsive Disorder and Anxiety Disorders: Impact on Symptom Severity and Impairment

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

Randomized,placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive–compulsive disorder

Background

To examine the efficacy of sequential sertraline and cognitive-behavioral therapy (CBT) treatment relative to CBT with pill placebo over 18 weeks in children and adolescents with obsessive–compulsive disorder (OCD).

Methods

Forty-seven children and adolescents with OCD (Range = 7–17 years) were randomized to 18-weeks of treatment in one of three arms: 1) sertraline at standard dosing + CBT (RegSert + CBT); 2) sertraline titrated slowly but achieving at least 8 weeks on the maximally tolerated daily dose + CBT (SloSert + CBT); or 3) pill placebo + CBT (PBO + CBT). Assessments were conducted at screening, baseline, weeks 1–9, 13, and 17, and post-treatment. Raters and clinicians were blinded to sertraline (but not CBT) randomization status. Primary outcomes included the Children's Yale-Brown Obsessive–Compulsive Scale, and response and remission status. Secondary outcomes included the Child Obsessive Compulsive Impact Scale–Parent/Child, Children's Depression Rating Scale-Revised, Multidimensional Anxiety Scale for Children, and Clinical-Global Impressions-Severity.

Results

All groups exhibited large within-group effects across outcomes. There was no group by time interaction across all outcomes suggesting that group changes over time were comparable.

Conclusions

Among youth with OCD, there was no evidence that sequentially provided sertraline with CBT differed from those receiving placebo with CBT.

ClinicalTrials.gov Identifier

NCT00382291.     

Psychotherapy and (or) Medications for Depression in Youth? An Evidence-Based Review with Recommendations for Treatment

This article reviews existing research pertaining to antidepressant medications, psychotherapy, and their combined efficacy in the treatment of clinical depression in youth. Based on this review, we recommend that youth depression and its treatment can be readily understood from a social-psycho-bio model. We maintain that this model presents an alternative conceptualization to the dominant biopsychosocial model, which implies the primacy of biological contributors. Further, our review indicates that psychotherapy should be the frontline treatment for youth with depression and that little scientific evidence suggests that combined psychotherapy and medication treatment is more effective than psychotherapy alone. Due primarily to safety issues, selective serotonin reuptake inhibitors should be initiated only in conjunction with psychotherapy and/or supportive monitoring.     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Psychotherapie oder Psychopharmakotherapie oder Kombinationstherapie?

Current meta-analyses convincingly show the effectiveness of psychotherapy. For many mental disorders psychotherapy is the therapy of choice and superior to an exclusive pharmacotherapy. A psychotherapy is still effective far beyond the end of psychotherapy. Mild and moderate depressive episodes can be successfully treated by psychotherapy alone. A combination treatment is indicated for severe depressive episodes and a chronic course. Cognitive behavior therapy (CBT) is the method of choice for anxiety disorders where CBT can be initiated in order to build up self-efficacy and medication can be omitted at first. A combination treatment is only indicated when the response is insufficient. For obsessive-compulsive disorder with predominantly compulsive behavior CBT with exposure and reaction management is the method of choice. Combination treatment is indicated particularly for predominantly obsessive thoughts and comorbid depression. In posttraumatic stress disorder a trauma-focussed CBT is the method of choice. For posttraumatic stress disorder selective serotonin reuptake inhibitors are indicated only for comorbid disorders. For all disorders benzodiazepines should be prescribed only in justifiable exceptional cases for short-term administration. For individualized differential indications the effects of simultaneous psychopharmacotherapy on the therapeutic process must be taken into consideration.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

Addressing Barriers to Change in the Treatment of Childhood Obsessive Compulsive Disorder

Although considerable evidence supports the use of cognitive behavior therapy (CBT) for the treatment of childhood obsessive compulsive disorder, large numbers of youth fail to respond and clinical remission is often elusive. Poor family functioning frequently is implicated as an obstacle for youth undergoing CBT, with features such as symptom accommodation, family conflict, and blame known to attenuate outcomes. These features are common in child and adolescent obsessive compulsive disorder (OCD) and they may pose particular challenges for exposure-based treatments. Nonetheless, interventions that focus specifically on family functioning have, to date, been limited. This paper reviews the literature on family features associated with childhood OCD and discusses their links to treatment outcome. It then describes the development of a brief family intervention tailored to address the needs of highly distressed families of youth with OCD in the service of improving individual child CBT outcomes. Preliminary pilot data are presented and clinical implications are discussed.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

Combining Pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone

Cambodian refugees with posttraumatic stress disorder (PTSD) represent a cohort in severe need of treatment, but little information is available to guide treatment choices. We selected a sample of pharmacotherapy-refractory individuals to test the efficacy of combination treatment with sertraline and cognitive-behavior therapy (CBT) for treating PTSD. Participants in this pilot study were ten Khmer-speaking women who had been at a mean age of 22-26 years during the Pol Pot period (1975-1979). These patients were randomly assigned to either sertraline alone or combined treatment. We found that combined treatment offered additional benefit in the range of medium to large effect sizes for PTSD and associated symptoms. Our findings indicate that substantial gains can be achieved by adding CBT to pharmacotherapy for PTSD, and that a program of CBT emphasizing information, exposure, and cognitive-restructuring can be successfully modified for Khmer-speaking refugees.     

Cognitive-behavior therapy for discontinuation of SSRI treatment of panic disorder: a case series

In this report we describe the outcome of eight outpatients with panic disorder and agoraphobia who discontinued their treatment with a selective serotonin reuptake inhibitor (SSRI) in the context of a structured, group program of cognitive-behavior therapy. All patients successfully discontinued their SSRI medication while demonstrating clinical improvement. These results were maintained at 3-month follow-up. This case series suggests that manualized CBT for discontinuation of benzodiazepine treatment for panic disorder may be successfully applied to SSRI discontinuation as well.     

Defining Treatment Outcomes in Pediatric Obsessive-Compulsive Disorder Using a Self-Report Scale

This study examined benchmarks of treatment response and clinical remission on the Obsessive Compulsive Inventory–Child Version (OCI-CV) for youth with obsessive-compulsive disorder (OCD). Participants were 91 youth who enrolled in a randomized controlled trial that examined the benefit of augmenting cognitive behavior therapy (CBT) with either d-cycloserine or placebo. Youth completed the OCI-CV at baseline, Week 4 (prior to initiating exposure therapy), and posttreatment. Receiver operator curve (ROC) analyses examined optimal benchmarks for treatment response and clinical remission as identified by independent evaluators at the posttreatment assessment using the Clinical Global Impression (CGI) scales of Improvement (CGI-Improvement), Severity (CGI-Severity), and Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Optimal benchmarks for treatment response were a 20%–25% reduction in the OCI-CV total score. Meanwhile, optimal benchmarks for remission were a 55%–65% reduction in the OCI-CV total score and a posttreatment total score ≤ 6-8. OCI-CV benchmarks exhibited moderate agreement with the CY-BOCS for treatment response and clinical remission. Meanwhile, fair agreement was observed for response and remission with CGI scales. A lower pretreatment OCI-CV total score was associated with less agreement between classification approaches. Findings provide benchmarks for classifying treatment response and clinical remission in an efficient manner. Given the moderate agreement between the CY-BOCS and OCI-CV benchmarks, the OCI-CV may serve as a useful alternative when clinician-rated scales cannot be administered due to limited resources (e.g., time, training). Thus, evidence-based measurement can be incorporated to monitor therapeutic response and remission in clinical practice.     

Patterns of Response and Remission Following a One-Session Treatment for Blood-Injection-Injury Phobia in Youth

Blood-Injection-Injury (BII) Phobia is a severe and impairing disorder that has been understudied in youth. The present study aimed to define patterns of response and remission following a modified One-Session Treatment (OST) including an e-therapy maintenance program for children and adolescents with BII Phobia. Moreover, characteristics of different responder groups were examined in order to determine correlates of a poorer response. Youth (n?=?20; 8–18 years) were categorized into four responder groups (e.g., immediate remitter, delayed remitter, partial responder, and nonresponder) based upon defined criteria for remission. Immediate remitters to treatment were more likely to have a primary diagnosis of injection phobia, rather than a combined blood and injection phobia. Nonresponders reported significantly greater disgust sensitivity at pretreatment and were more likely to have a comorbid diagnosis of Social Phobia. In regards to within session change, youth who achieved the exposure goal of having a blood test during treatment had a significantly stronger treatment response. These preliminary findings may assist clinicians in the planning and delivering of intensive Cognitive Behavioral Treatment (CBT) approaches for BII Phobia in youth.     

Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1 year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.     

Long-term efficacy of exposure and ritual prevention therapy and serotonergic medications for obsessive-compulsive disorder

What is the long-term outcome of patients with obsessive-compulsive disorder (OCD) who are treated with exposure and response (ritual) prevention (EX/RP) alone, serotonergic medications alone, or their combination? How is the long-term outcome of these patients affected by the discontinuation? Follow-up assessments were conducted with 62 patients treated for OCD an average of 17 months posttreatment (range: 6-43 months). Patients received one of three treatments: serotonergic medications (fluvoxamine or clomipramine), intensive behavior therapy involving EX/RP, or intensive EX/RP with concurrent antidepressant medication. At follow-up, no differences in OCD symptom severity were found among the three treatment groups. However, when current medication use was taken into consideration, differences among the three treatment groups emerged. Among patients who were medication-free at the time of follow-up assessment (n=37), those in the EX/RP-alone and EX/RP-with-medication groups had lower symptom severity ratings than those in the medication-only group on 4 out of 6 measures. There were no differences in OCD severity ratings among patients taking medications at follow-up (n=25). Although these findings are interpreted with caution due to the uncontrolled nature of the study, results suggested that long-term outcome may be superior following EX/RP than following serotonergic medications, after discontinuation. For patients who remain on medications, the treatment produced benefits equivalent to EX/RP.     

Sequential combinations of drug and cognitive behavioral therapy for chronic insomnia: an exploratory study

This study explores the efficacy of sequential treatments involving medication and cognitive behavioral treatment (CBT) for primary insomnia. Seventeen participants took part in a multiple baseline design and were assigned to: (a) medication for 5 weeks, followed by combined medication plus CBT for 5 weeks; (b) combined treatment for 5 weeks, followed by CBT alone; or (c) CBT alone. Each treatment sequence produced significant sleep improvements, but at different points in time. For the first sequence, most of the sleep improvement was obtained after the introduction of CBT, while for the other sequence and CBT alone, improvement appeared during the first weeks. These results suggest that sleep improvement seems affected by the way treatments are combined. Also, a sequence beginning with a combined treatment followed by CBT alone seems to produce the best outcome. Additional research should be conducted with larger samples to determine the most effective sequence.     

Long-Term Outcomes of Youth Treated for an Anxiety Disorder: A Critical Review

Pediatric anxiety disorders are common, disabling, and chronic conditions. Efforts over the past two decades have focused on developing and testing effective treatments. Short-term efficacy of both Cognitive Behavioral Therapy (CBT) and selective serotonin reuptake inhibitors has been established. Data are emerging on the long-term (i.e., 2 years or longer) effectiveness of these treatments, but this literature has yet to be adequately synthesized. This study presents a systematic and critical qualitative review of published long-term follow-up (LTFU) studies of youth treated for an anxiety disorder. A comprehensive search of several databases identified 21 published reports (representing 15 LTFU cohorts of treated youth) meeting specified inclusion criteria. LTFU assessments occurred a mean of 5.85 years after initial treatment (range 2–19 years). Diagnostic rates at LTFU and predictors (e.g., demographic, baseline child clinical variables, treatment type) of outcomes at LTFU were also examined. A discussion of the limitations of this literature is provided to qualify interpretations of findings and to inform future studies. Findings can aid clinicians and families in making treatment decisions and setting reasonable expectations for the long-term prognosis after treatment for anxiety.